BP situation - page 2

by Standoe3

4,464 Views | 29 Comments

I just completed my orientation and was released so I am a newgrad LVN working fulltime days. I had a situation with a pt who has a Hx of HR of 60 at best he has bottomed out before around 45bpm when given meds. I gave lasix,... Read More


  1. 0
    You did the right thing.......Good job!

    If the heart rate was lower or this was new (the heart rate in the 60's) for this patient....I would have second thoughts....i would also have checked when the last dig level was performed and suggest to the MD it might be time to check another level.

    So if the patient normally had a resting heart rate of 80 and it is 58 I would not give the med with or without the MD's permission.....or if the patient had a slightly elevated dig level a month ago....I would ask if the med could be held until a new level was secured.
  2. 0
    Sometimes doctors still decide to give a medication if the benefits outweigh the risks. You notified the MD of the patient's VS and yet they still wanted the dig to be given. YOU DID THE RIGHT THING! As Esme stated, I also would have looked at the dig level and suggest another level be performed if it hadn't been done in awhile.
  3. 0
    All the feedback is great! Thx for all your input everyone
  4. 3
    After reading through the OP's description of the issue a couple of times, I cannot find anything that was done incorrectly. The patient's HR was ~60 prior to the med, and dropped to 48 occasionally with a SBP just under 100. A lot of folks "live" at those levels and do quite well. I still recall a very smart and experienced doc explaining this with the analogy of, "fifty is nifty," meaning if the HR is > 50, and all else is OK, then give the med. I have never seen any patient bottom out in any scenario as originally described.
  5. 0
    The MD is the one with the final call as to whether it's appropriate to give the med - unless you're certain that it's grossly unsafe - in which case you need to elevate the issue thorugh nursing and medical supervision - and be prepared to be taken to task for same.

    In this case, with the patient hemodynamically stable and the HR in the mid- to high-50's, once I'd reviewed the patient's status with the MD and clarified his/her desire to administer the medication, I would proceed (and, of course, carefully and thoroughly document the situation in real time).

    To answer your hypothetical: What about the converse? You decide to override the MDs judgement and an adverse outcome occurs...

    It is the MD's role to decide appropriate treatment so long as they have full knowledge of the patient's condition and status; making him/her aware of same is the RN's role.
  6. 1
    I would not have held Digoxin for a HR of 60. For a HR of 50 or less, I would definitely call the physician unless there were written parameters in place that stated otherwise. BP is not so much of a concern with digoxin, as it is a positive inotrope and slows AV nodal conduction and has no effect on SVR.

    In the absence of written parameters (i.e. hold for HR <50 and notify MD), if my patient were in that 50-60 range, I might wait a few minutes and come back and recheck HR a little while later. I'd also try to determine whether they've been on digoxin for a long time, or if this is a new medication for them. I'd look at VS trends, and of course, I'd assess them for any signs/symptoms of poor perfusion.

    If the person has been taking digoxin for 10 years, routinely has a HR of 50-60, and is tolerating their current HR without any adverse s/s, I'd give it. If this were a new medication for them, HR typically 60 or greater, and/or c/o dizziness, chest pressure/tightness, and/or dyspnea, I'd hold and call. And of course, if the patient is A&O, talk to them. Ask them how long they've been taking it and how it usually affects them.

    Medications like digoxin should have parameters attached. If there are no parameters and you have any concerns, call the physician and ask for them.
    cardiacrocks likes this.
  7. 0
    Quote from ~*Stargazer*~
    Medications like digoxin should have parameters attached. If there are no parameters and you have any concerns, call the physician and ask for them.
    Still a student and would like to ask a question, if I may. I've only done one clinical rotation and it was in ltc. The patients with whom I had contact DID have HR parameters set, not only for dig, but also for antihypertensives, and in at least one case, a parameter for SBP.

    Is this the norm or did I just luck out and should expect that more often than not it will be as in the OP's case, where there is no written parameter?

    It's difficult to learn in advance of actually having the patient experience, but being able to lurk in this forum is the next best thing. So thank all of you for that.
  8. 1
    None of those VS from the OP really "scare" me. I have seen "hold" parameters as low as "hold for HR<45" and "hold for SBP <90." In other words, for this pt, those VS might have been totally appropriate for those meds. Were these new meds or meds the pt was already on at home?

    I definitely think you handled it well. My only suggestions: 1. Chart the specific name of the doc/time of the conversation...example "Dr. Smith at BS at 1500. Alerted Dr. Smith of VS, HR 54 BP 98/63. Per Dr. Smith, digoxin given as ordered." 2. You may have done this anyway--make sure you chart VS regularly to show that you were monitoring the pt's response to the meds.
    ~*Stargazer*~ likes this.
  9. 0
    Quote from Sadala
    Still a student and would like to ask a question, if I may. I've only done one clinical rotation and it was in ltc. The patients with whom I had contact DID have HR parameters set, not only for dig, but also for antihypertensives, and in at least one case, a parameter for SBP.

    Is this the norm or did I just luck out and should expect that more often than not it will be as in the OP's case, where there is no written parameter?

    It's difficult to learn in advance of actually having the patient experience, but being able to lurk in this forum is the next best thing. So thank all of you for that.
    I'm not sure of the norm in LTC. In the hospital I have pretty much always seen parameters for Beta blockers, ACE inhibitors, dig...and probably some others I can't think of right now.
  10. 0
    It depends on the hospital I think and the doctors. If the MD gives parameters with the order they are place in our computer system but if not they are not there.....as a student don't assume that parameters will be listed for all BP drugs and make it a habit to document the V/S with all BP meds that extra step will save ur license


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